Insurance Claim Denied in Brazil? How to Appeal

Brazil has one of Latin America's most robust consumer protection frameworks for insurance, combining the Código de Defesa do Consumidor (CDC), SUSEP for general insurance, and ANS specifically for health insurance (planos de saúde). If your claim has been denied, here's how to fight back.

Key Regulators in Brazil

SUSEP — Superintendência de Seguros Privados

Brazil's insurance supervisor for life, property, casualty, and reinsurance — under the Ministry of Finance. SUSEP licenses and oversees all private insurance companies (except health plans, which are under ANS).

Website: susep.gov.br | Complaint portal: seic.susep.gov.br

ANS — Agência Nacional de Saúde Suplementar

Brazil's health plan regulator — one of the most important insurance regulators for consumers. ANS regulates all planos de saúde (private health plans) and enforces:

• The minimum coverage list (Rol de Procedimentos e Eventos em Saúde) — a legally binding list of procedures that all health plans must cover
• Denial appeal procedures
• Waiting period limits

Website: ans.gov.br | Phone: 0800 701 9656 (NovoCentral) Online dispute: http://www.ans.gov.br/planos-de-saude-e-operadoras/contratacao-e-troca-de-plano/rir-notificacao-de-intermediacao-preliminar

PROCON

Each state has a PROCON (consumer protection agency) that handles disputes under the CDC. PROCON can mediate and apply fines for violations of consumer rights.

Defensoria Pública

Brazil's public defenders provide free legal services to low-income individuals, including representation in insurance disputes. Very effective for health plan denials — Defensorias have extensive experience suing health plans.

Your Rights Under Brazilian Law

Código de Defesa do Consumidor (CDC — Law 8,078/1990)

The CDC governs all consumer-supplier relationships in Brazil, including insurance contracts:

1. Clarity and information: All policy terms must be clear, precise, and in easy-to-understand Portuguese. Abusive or obscure clauses are void (Art. 51 CDC).

2. Contra proferentem: Ambiguous clauses in adhesion contracts (standard form contracts, like most insurance policies) are interpreted in favor of the consumer (Art. 47 CDC).

3. Abusive clauses: Clauses that excessively burden the consumer or give the supplier disproportionate advantages are null and void (Art. 51, XIV CDC).

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ANS Regulations for Health Plans

The Rol de Procedimentos (ANS Normative Resolution No. 465/2021 and updates): All health plans must cover every procedure on this list. If the ANS Rol covers your treatment, denial is unlawful.

Law 9,656/1998 (Lei dos Planos de Saúde):

• Waiting periods are capped: 24 hours for emergencies, 30 days for urgent hospitalization, 180 days for elective procedures, 300 days for childbirth
• Pre-existing conditions: plans can exclude for up to 24 months for standard contracts; after 24 months, full coverage is mandatory
• No plan can refuse to renew coverage based on health status

ANS Resolution 529/2022: Health plans must respond to authorization requests within:

• 4 hours for urgency/emergency
• 3 business days for elective procedures
• 10 business days for high-complexity procedures

How to Appeal a Denied Health Plan Claim in Brazil

Step 1: Internal Appeal (Recurso Interno)

• Contact your health plan's SAC (Serviço de Atendimento ao Consumidor) by phone or written letter
• Request the specific denial reason and applicable policy exclusion in writing
• ANS requires health plans to maintain a 24/7 SAC

Step 2: ANS — NIP (Notificação de Intermediação Preliminar)

File an NIP (preliminary mediation notice) at the ANS portal:

• Fast: ANS requires the health plan to respond within 5 business days
• Free: no cost to file
• Effective: most health plan denials reverse at this stage or shortly after
• Available at: ans.gov.br/contato/rir

Step 3: PROCON Complaint

File with your state PROCON (procon.sp.gov.br for São Paulo, etc.):

• PROCON schedules a conciliation hearing between you and the insurer
• Fines for CDC violations: up to BRL 9.7 million per violation
• Creates a public record of the insurer's conduct

Step 4: Consumer Court (Juizado Especial Cível — JEC)

For claims up to 40 minimum wages (~BRL 56,000 in 2026), you can file in the JEC without a lawyer:

• Fast proceedings (typically 3–6 months)
• Courts often award moral damages (dano moral) in health plan denial cases — often BRL 5,000–30,000
• Juries are familiar with health plan denials and often rule in favor of consumers

Step 5: State Court (Vara Cível)

For larger claims or complex cases, regular civil courts with a lawyer. Brazil's courts have accumulated extensive precedent favorable to consumers in health plan disputes.

Private Life and P&C Insurance Complaints

For SUSEP-regulated insurers (life, auto, home), use SUSEP's SEIC online portal. SUSEP can investigate and order payment if the denial was unjustified.

Fight Back With ClaimBack

ClaimBack generates Brazil-specific insurance appeal letters citing ANS Rol de Procedimentos, CDC Article 47 contra proferentem, and ANS NIP procedure guidance.

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